V2R Online Rx Form

EN Please note that the Smile in a Box Jotform will close on September 30. To avoid any disruption, we encourage you to start placing your orders through Straumann AXS™ today.

FR Veuillez noter que le formulaire Smile in a Box fermera le 30 septembre. Afin d’éviter toute interruption, nous vous encourageons à commencer à passer vos commandes via Straumann AXS™ dès aujourd’hui.

IT Si prega di notare che il Jotform di Smile in a Box verrà chiuso il 30 settembre. Per evitare disguidi, la invitiamo a iniziare a effettuare i suoi ordini tramite Straumann AXS™ già da oggi.

ES Le informamos de que el Jotform de Smile in a Box se cerrará el 30 de septiembre. Para evitar cualquier inconveniente, le recomendamos que empiece a realizar sus pedidos a través de Straumann AXS™ desde hoy.

DE Bitte beachten Sie, dass das Smile in a Box Jotform am 30. September geschlossen wird. Um Unterbrechungen zu vermeiden, empfehlen wir Ihnen, Ihre Bestellungen ab sofort über Straumann AXS™ aufzugeben.

PT Informamos que o Jotform Smile in a Box será encerrado em 30 de setembro. Para evitar qualquer interrupção, incentivamos você a começar a fazer seus pedidos através do Straumann AXS™ ainda hoje.

Is this your first Smile in a Box case?*

YesNo

Customer name*

PrefixFirst NameLast Name

Customer e-mail address*

Please enter the e-mail address associated to your Smile in a Box clinician account.

Additional email address

Kindly provide, as necessary, the email address of your practice manager or an additional email address designated for the receipt of all communications

Prefered language

If you would like your case management in a different language, let us know and we will be happy to do so

Company name*

Shipping address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Phone number*

Mobile phone number (Optional)

Uncheck if you would like to unsubscribe from receiving text message notifications for this case

Straumann customer number*

Purchase Order Number

Should you need to add a PO, please enter it here. Note that all cases for the NHS, {my}dentist and BUPA require pre-authorisation.

Click here if you are submitting files for an ongoing case

Smile in a Box™ case reference number*

The 8-digit number used for all Smile in a Box communications

Patient Identifier*

Please provide a patient code or reference of your choice. We do not recommend providing names here.

Case type*

SingleMultiple unitsFull arch / edentulous

Condition and treatment scope

Arch*

Loading Approach

Temporary restoration

Condition

Additional clinical observations

Implant system*

Guided Surgery Kit Neodent*

Indicate the surgeon's dominant hand? *

Indicate the surgeon's working position? *

We request that you provide pictures of the surgeon's working position, for different implant sites. See the example below.

Guided Surgery Kit Anthogyr*

Indicate the surgeon's dominant hand? *

Indicate the surgeon's working position? *

We request that you provide pictures of the surgeon's working position, for different implant sites. See the example below.

Guided Surgery Kit Straumann*

Indicate the surgeon's dominant hand? *

Indicate the surgeon's working position? *

We request that you provide pictures of the surgeon's working position, for different implant sites. See the example below.

Browse Files

Please upload your picture(s) here

Preferred alignment*

Numbering system

Implant sites (US)

	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16

Implant sites (FDI)

	18	17	16	15	14	13	12	11	21	22	23	24	25	26	27	28

Implant sites (US)

	32	31	30	29	28	27	26	25	24	23	22	21	20	19	18	17

Implant sites (FDI)

	48	47	46	45	44	43	42	41	31	32	33	34	35	36	37	38

Preferred guided surgery solution*

Sequential pin-supported solutionStackable solution

Type a question

Click here for more information about the different guided surgery solutions

Additional instructions:

Would you like to order a temporary restoration?*

YesNo

Coloring/Shades

Tooth shade*

Arch Design*

Gum shade

Please note that only the shades A1 and B1 are available for the stackable provisional prosthesis.

Will you be providing a mock-up of the temporary?

YesNo

Please provide instructions and attach photos of the patient in section 6 (if available)

Should you want to expand on the information provided above and discuss prosthetics in more detail, please contact us (1-514-587-8359) or your partner lab.

Ordered services*

Full ServiceModular Service

Please select from the following services:*

Surgical treatment planning by coDiagnostiX™Digital wax-up design by CARES® VisualSurgical guide design by coDiagnostiX™Temporary restoration design by CARES® VisualCentralized manufacturing of the surgical guidesCentralized manufacturing of the temporary restorationComponent order (implants, abutments and auxiliaries)

Additional ordered services

Custom impression tray3D printed master model

Preferred treatment plan review method*

Interactive: Smile in a Box will contact you to schedule an online meeting to review and adjust the plan prior to submitting the report (mandatory for full arch restoration)Document-based: Smile in a Box will submit a report for you to review and approve

Preferred treatment plan review method*

Interactive: Smile in a Box will contact you to schedule an online meeting to review and adjust the plan prior to submitting the report (mandatory for full arch restoration)Document-based: Smile in a Box will submit a report for you to review and approve

Treatment plan printing options

Our current standard procedure is to provide you with a printed treatment plan. If you prefer not to receive it in print format, please click here.

Important note on surgery scheduling:

Please allow 8 business days for treatment planning and manufacturing of single-unit/multiple-unit case, and 20 business days for treatment planning and manufacturing of full arch/edentulous case, excluding shipping and considering less than 24hr treatment plan approval

Planned surgery date (if known, see above):

YearMonthDay

You might not receive your Smile in a Box order on time

The chosen services cannot be delivered at the chosen date. Please select a new date.

Need help? Access our Scanning Protocol.

Upload your files here (patient pictures, CT scans in DICOM format and models in .stl format)

Browse Files

Please upload all files in .zip format.

If your files cannot be uploaded, please provide a link to a cloud storage (dropbox, box, drive, hightail, etc.):

IOS Data Exchange Case ID from your Virtuo Vivo™, Medit or 3shape scanner

Optional

General Notes

0/200

Signature*

Firma*

Please wait for the confirmation prior to navigating away from this page. Upon successful submission, you will also receive an e-mail confirmation.

1. Patient information

2. Implant configuration

STRAUMANN® FALCON

STRAUMANN® FALCON

STRAUMANN® FALCON

3. Prosthetic design

4. What would you like to include with your order?

5. Treatment Scheduling

6. File upload and submission